Disclosure of Relevant Financial Relationships
Continuing Education & Professional Development
Regularly Scheduled Series: Internal Medicine Grand Rounds
Session Date(s):
Location, City, State: 3015 Sudler Auditorium, Kansas City, KS
Presentation/Content Description:
Name and Degree(s):
All individuals involved in the content, design, or implementation
of an accredited Continuing Education (CE) activity must complete and return page 1.
A conflict of interest (potential for bias) exists if an individual that is in a position to benefit financially from the success
of a CE activity is also in a position to influence the content, design, or implementation of the CE activity.
A commercial interest is any entity either producing, marketing, re-selling, or distributing healthcare goods or services
consumed by, or used on, patients, or an entity that is owned or controlled by an entity that produces, markets, re-sells, or
distributes healthcare goods or services consumed by, or used on, patients. Nonprofit or government organizations, nonhealthcare-related companies, and healthcare facilities are not considered commercial interests.
Having read the above statements, please check either A or B:
A.
NO, within the past 12 months, I and/or my spouse/partner did not have potentially biasing relationships of a financial,
professional, or personal nature with any commercial interests that would constitute a conflict of interest related to this
activity. Read page 2 and sign below.
B.
YES, within the past 12 months, I and/or my spouse/partner did have potentially biasing relationships of a financial,
professional, or personal nature with commercial interests that would constitute a conflict of interest related to this
activity. Complete the table below, attaching additional information if needed. You will be contacted to resolve any potential
conflict of interest.
Nature of Financial Relationship
End Date
Commercial Interest
For what role?
What was received?
(If applicable)
(Do not provide dollar amount.)
Example: Company ‘X’
Honorarium
Speaker
12/1/2013
/
/
/
/
/
/
/
/
I HAVE CAREFULLY READ AND COMPLETED MY DISCLOSURE. I AGREE TO COMPLY WITH THE CONTINUING
EDUCATION TERMS AND CONDITIONS NOTED ON PAGE 2 AS THEY APPLY TO MY RESPONSIBILITIES .
↑
Signature ↑ Type speaker name here
PLEASE COMPLETE AND RETURN PAGE 1 TO
↑
BY
Date ↑
VIA E-MAIL
OR FAX
.
For Office Use Only / ANCC
Disclosure and documentation of expertise (CV, res me, biography, or additional documentation acquired) have been reviewed
and no actual/potential relevant financial relationships were identified.
Documentation of expertise was reviewed and determined appropriate for activity responsibilities.
Actual/potential COI was identified and resolved (Resolution of COI Checklist).
Reviewer Signature (handwritten or electronic with accompanying email/fax
Date
Rev. 6/27/2013
Page 1
Imp. 7/1/2013
(Continued from page 1)
Disclosure of Relevant Financial Relationships
KUMC Continuing Education & Professional Development
Continuing Education Terms and Conditions
Please review each section applicable to your responsibilities. If you agree, please sign, date, and return page 1 only.
Applicable to Planning Committee Members and Content Reviewers
My contribution regarding content will:
 Be based on objectives designed to facilitate the maintenance of competence of healthcare professionals in practice;
 Include a balanced view of therapeutic options;
 Represent the best available evidence accepted in health professional practice;
 Be based on conclusions or inferences about the evidence that are accepted in the general health care community as valid and sound;
 Help ensure that all scientific research referred to in this presentation, including research in support or justification of patient care
recommendations, conforms to generally accepted standards of experimental design, data collection, and analysis; and
 Help ensure that content is accurate and includes adequate justification for indications and contraindications in the care of patients.
Applicable to Speakers and Moderators
My presentation will be based on acceptable principles that are generally accepted as valid by the professions. The content will be
based on educational objectives designed to facilitate the maintenance of competence of health care professionals in practice.
Content will be based on conclusions or inferences about the evidence that are accepted in the general health care community as valid
and sound.
Scientific research referred to in this presentation, including research in support or justification of patient care recommendations,
will conform to generally accepted standards of experimental design, data collection, and analysis.
Content will be accurate and based on best information available at the time the presentation is developed.
This will include adequate justification for indications and contraindications in the care of patients.
If addressing unlabeled and/or unapproved uses I will clearly acknowledge the unlabeled identification or the investigational nature of
drug products and/or devices to the learners.
I will prepare fair and balanced presentations that are objective and scientifically rigorous. Content – including therapeutic options,
recommendation, or emphasis – will be well-balanced, evidence based where possible and unbiased. Source and type of evidence will
be made clear to the participants and be HIPAA compliant, i.e., I will only use de-identified patient information. No single product or
service will be over represented when other equal but competing products or services are available for inclusion.
I will use generic names to the extent possible when discussing specific health care products or service. If trade names are used, I will
use trade names from several companies when available, and not just trade names from any single company.
I understand that activity planners may need to review my presentation and/or content prior to the activity and I will provide
educational content and resources in advance as requested.
Handouts and slides will not include my company logo other than on the first slide.
The copyright symbol may be included on each of the slides.
I will not include any advertising, trade names or product-group messages in any of the educational materials for this CE activity
(slides, abstract, handouts, etc.).
Applicable to All Individuals
I have not and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly
with KUMC Continuing Education for this activity.
If I have been trained or utilized by a commercial entity or its agent as a speaker for any commercial interest, the promotional aspects
of that presentation will not be included in this activity.
If content includes research funded by a commercial company, I will help plan the activity and my presentation so that the information
presented will be based on generally accepted scientific principles and methods. I will not promote the commercial interest of the
funding company.
I understand that participants will evaluate my compliance to these requirements.
If my disclosure changes, I will submit a revised Disclosure of Re levant Financial Relationships form.
Rev. 6/27/2013
Imp. 7/1/2013
Page 2
(Continued from page 2)
Disclosure of Relevant Financial Relationships
KUMC Continuing Education & Professional Development
Accreditation Council for Continuing Medical Education (ACCME) Glossary of Terms
http://www.accme.org/sites/default/files/null/11_Glossary_of_Terms_20100420_1.pdf
Commercial interest
A commercial interest, as defined by the ACCME, is any entity producing, marketing, re-selling, or distributing health care goods
or services consumed by, or used on patients. The ACCME does not consider providers of clinical service directly to patients to be
commercial interests. A commercial interest is not eligible for ACCME accreditation.
Conflict of interest
The ACCME considers financial relationships to create conflicts of interest in CME when individuals have both a financial
relationship with a commercial interest and the opportunity to affect the content of CME about the products or services of that
commercial interest. The potential for maintaining or increasing the value of the financial relationship with the commercial interest
creates an incentive to influence the content of the CME—an incentive to insert commercial bias.
Relevant financial relationships
The ACCME requires anyone in control of CME content to disclose relevant financial relationships to the accredited provider.
Individuals must also include in their disclosure the relevant financial relationships of a spouse or partner. The ACCME defines
relevant financial relationships in any amount that create a conflict of interest and that occurred in the twelve-month period
preceding the time that the individual was asked to assume a role controlling content of the CME activity. The ACCME has not set
a minimal dollar amount—any amount, regardless of how small creates the incentive to maintain or increase the value of the
relationship. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty,
intellectual property rights, consulting fee, honoraria for promotional speakers’ bureau, ownership interest (e.g., stocks, stock
options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually
associated with roles such as employment, management position, independent contractor (including contracted research),
consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities
from which remuneration is received, or expected.
American Nurses Credentialing Center (ANCC) Definitions
(2013 ANCC Accreditation Manual, pages 28-29)
Commercial Interest
Commercial interest, as defined by ANCC is any entity either producing, marketing, re-selling, or distributing healthcare goods or
services consumed by, or used on, patients, or an entity that is owned or controlled by an entity that produces, markets, re-sells, or
distributes healthcare goods or services consumed by, or used on, patients. Nonprofit or government organizations, non-healthcarerelated companies, and healthcare facilities are not considered commercial interests.
Conflict of interest
Conflict of Interest is considered an affiliation or relationship with a Commercial Interest Organization of a financial nature that
might bias a person’s ability to objectively participate in the planning, implementation, or review of a learning activity.
Relevant financial relationships
Relevant relationships as defined by ANCC, are relationships with a commercial interest if the products or services of the
commercial interest are related to the content of the activity.

Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be
reported, evaluated, and resolved.

Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty,
intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified
mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.

Financial benefits may be associated with employment, management positions, independent contractor relationships, other
contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board
membership, and other activities from which remuneration is received or expected from the commercial interest.
Rev. 6/27/2013
Imp. 7/1/2013
Page 3